Comment and Response Document For our DRAFT Benign Skin Lesion LCD

Comment: I believe that the updated proposed Benign LCD is excellent. Upon reading the draft I have a few comments that I hope you will consider: Reference to the 17000 code series under "coding information" should be deleted as this policy does not address those codes. The 17000 series is addressed by the National CMS actinic keratosis policy.

Response: We have removed the paragraph that addressed codes 17000-17004 in our billing and coding document.

Comment: Of the codes suggested for deletion, I would recommend that 701.8 other specified hypertrophic conditions of skin be added back into the policy as there as some processes that may be causing functional problems for patients that can be relieved by excising them. The other codes can safely be deleted.

Response: ICD-9 code 701.8 and ICD-010 codes L11.8, L66.4, L85.8,L87.1, L87.8, L90.3, L90.4, L90.8, L91.8, L92.2, L98.5,L98.6 and L99 have been added to the policy.

Comment: I would recommend adding 709.2/L90.5 scar and 701.4/L91.0 keloid. These can be painful and cause functional deficits by causing contractures and judicious surgical excision may provide relief to patients.

Response: Our draft policy includes diagnosis codes 701.4 keloid scar /L91.0 Hypertrophic scar. We have added 709.2-scar conditions and fibrosis of skin/L90.5 scar conditions and fibrosis of skin to the policy.

Comment: Does Medicare cover laser scar treatments? Some expert dermatologists think CPT codes 17110 and 17111are appropriate codes to use for this service and should be covered by insurance.

Response: Our LCD states that the removal of certain benign skin lesions that does not pose a threat to health or function, are considered cosmetic and as such are not covered by the Medicare program. There may be instances in which the removal of non‐malignant skin lesions is medically appropriate. Medicare will, therefore, consider their removal as medically necessary and not cosmetic, if one or more of the following conditions are present and clearly documented in the medical record: 1. The lesion has one or more of the following characteristics: bleeding, itching, pain; change in physical appearance (reddening or pigmentary change), recent enlargement, increase in number; or 2. The lesion has physical evidence of inflammation, e.g., purulence, edema, erythema; or 3. The lesion obstructs an orifice; or 4. The lesion clinically restricts vision.

Comment: How would case of excision for inflammatory conditions such as panniculitis be addressed, as based on the benign lesion policy those would not be covered? In order to get enough tissue to make a definitive diagnosis, an excision into fat may be needed. Adding codes for all such conditions would seem to make the policy quite unwieldy.

Response: CPT code 15830 excision, excessive skin and subcutaneous tissue (includes lipectomy); abdomen, infraumbilical panniculectomy would not fall under the purview of this policy. Panniculitis is not covered when it is performed to improve patient appearance. This information is in our Cosmetic and Reconstructive Surgery LCD (L30733).

Comment: At times, it becomes necessary to perform an excision of an ulcer once the underlying cause has been addressed and eliminated. In the past, under the current LCD, I had used ICD-9 codes 701.8 (other specified hypertrophic and atrophic conditions of skin). I would think that 709.3 (degenerative skin disorders) could also apply. Under the DRAFT LCD, these 2 codes were eliminated.

I would propose that these codes be maintained within the DERM DRAFT LCD for the excision of an ulcer rather than including all of the ulcer codes available. The excision of an ulcer is not commonly performed, but it would be nice to have a code that can be used for this circumstance. In the Wound Care LCD, excision codes (11420 - 11426) do not exist.

Response: See above, diagnosis code 701.8 has been added to the policy. The CPT codes discussed in this policy only apply to the removal of benign skin lesions. Ulcers are not considered benign skin lesions. CPT Codes 15920-15999 are codes that are for the excision of pressure ulceration and require tissue removal. Debridement of the ulcers would be coded with 97597 & 95798 codes.

Comment: Since Medicare Advantage policy follow local coverage determinations, we also suggest mentioning the Actinic Keratosis National Coverage Determination 250.4 which covers the removals of Actinic Keratosis (702.0).

Response: We reference the National Coverage Determination for Actinic Keratosis in these 2 sections of our policy:

CMS National Coverage Policy CMS 100-03 Medicare National Coverage Determinations Manual-Chapter 1, Coverage Determinations, Part 4, Section 250.4 - Treatment of Actinic Keratosis

ICD-9 Codes that Support Medical Necessity NOTE: National Coverage Determination 250.4 outlines coverage for the treatment of actinic keratosis (AK) diagnosis code 702.0.

Comment: We believe the draft LCD is straightforward and a clearly conceptualized document. We would like to respectfully submit some comments for a better understanding and coverage of benign lesion removals. Our comments are mainly focused on content changes to enhance accuracy. We request the following diagnoses codes be added to reflect the clinical work performed by Dermatologists. 042 HUMAN IMMUNODEFICIENCY VIRUS (HIV) 239.2 NEOPLASM OF UNSPECIFIED NATURE OF BONE, SOFT TISSUE AND SKIN 279.00 HYPOGAMMAGLOBULINEMIA UNSPECIFIED 528.4 CYSTS OF ORAL SOFT TISSUES 624.01 VULVAR INTRAEPITHELIAL NEOPLASIA I [VIN I] 624.02 VULVAR INTRAEPITHELIA LNEOPLASIA II [VIN II] 682.0-9 CELLULITIS AND ABSCESS OF FACE, etc 709.3 DEGENERATIVE SKIN DISORDERS 727.40 SYNOVIAL CYST UNSPECIFIED V58.44 AFTERCARE FOLLOWING ORGAN TRANSPLANT

Response: This LCD is addressing the removal of benign skin lesions only. It does not address the clinical work performed by Dermatologists. Diagnosis codes 624.01 and 624.02 are in our draft policy. Your request did not include any supporting documentation or literature adding these diseases to our policy. The diagnosis code 042-HIV and 279.0 hypommaglobulinemia unspecified would not be specific enough to document what is being excised.